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Student

Name: Ashley Moore

Case: #3

Date: 2/10/14

1. Diagnosis, Referral, Setting, Reimbursement, LOS


Diagnosis: Carpal Tunnel (right and left), Trigger Thumb (left), and Rheumatoid Arthritis
Referral: Source of referral is unclear from documentation. However, it is likely that Marlenes physician,
Dr. Joffe, made the referral.
Setting: Outpatient through IHC Avenues Sports Therapy and Rehabilitation
Reimbursement: Workers compensation
LOS: 2x/week for 2 weeks; then 1x per week; estimated D/C is 1/31. (Approximately 10 sessions)
2. Pragmatic Factors to Consider
If Marlene decides to have left carpal tunnel surgery, this will impact various aspects of the therapy
process:
-It will decrease pain and increase function in the long run but will temporarily limit participation in
activities that involve the hand.
-Hand strength temporarily will decrease even further (temporarily).
-OT services will not be able to assist with new issues/needs if Marlene has CTR surgery after her two
months of therapy are over.
-Depending on how much time she has off from work, Marlene may be able to plan a CTR surgery during
her days off at Christmastime. She may be around family/friends for the holiday who can assist her with
household tasks.
Outpatient setting allows for the opportunity to address a variety of occupational areas.
Workers Compensation therapy priorities will be work/career related. They may not be willing to pay for
sessions that address Marlenes priorities in other areas.
Marlene lives alone and is therefore responsible for many home management activities. This affects the
recommendations that can be made in this area.
Her rehab potential in her right hand was listed as good. Her left rehab potential was listed as fair,
however, she is left hand dominant and needs both hands for to complete job duties. Repetitive work
activities that she needs to do regularly (typing) must be limited.
If the braces ordered by the doctor are heavy, they may actually decrease function in worn during
demanding daily activities because of RA symptoms of fatigue. Light splints could be a better fit.
Regardless, the occupational therapist should also ensure that the Marlene understands how to wear the
braces properly to decrease median nerve pain and increase function.
Two of Marlenes hand conditions (CTS and trigger thumb) can be remedied (at least partially) through
activity modifications to decrease repetitive use.
Rheumatoid arthritis is a previously diagnosed condition; therefore, insurance may not pay for treatments
that address this condition. However, research has demonstrated that this condition is a potential cause of
both carpal tunnel and trigger finger. Therefore, it should be addressed in therapy to elicit optimal results.

Cultural:

Physical:

3. Context: Occupational Profile & Current Occupations


Marlene lives in a culture (American) that values productivity and achievement.
Belongs to an artsy culture as her hobbies include many art forms.
Belongs to the culture of having a chronic health condition.
Marlene works in an office:
-Personal desk and computer
-Standing reception area
-Works with books phones
She goes to theatres and concert venues

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Social:

Personal:

Temporal:

Virtual:

One of Marlenes job duties includes meeting one on one with planners and
administrators in her company.
One of her job duties includes answering questions for people at a reception area.
She is not married currently.
Marlene is a 32-year-old woman.
She is reference consultant for a scientific research company
She enjoys cooking, reading, watching TV, going to plays and concerts, and listening
to classical music.
She is left hand dominant.
She was diagnosed with Rhematoid Arthritis 10 months ago.
Her RA cam on very suddenly.
It is wintertime.
She has spent the past 5-6 weeks on a special project that has required more time on the
computer.
She has approximately 2 months of occupational therapy services.
First seen for worsening of symptoms two weeks ago.
She uses a computer for most of her work (about 20-30 hours per week).
She uses a phone for work communication on a regular basis and likely has a personal
cell phone.
She enjoys watching TV.

Prior Occupations:
Worked full time as a research consultant where she works on a computer at a desk, answers phones, meets
with company administrators, handles books, and answers questions at a reception area.
Recently, she had been working as a special project and spending more time on the computer.
She cooked, watched TV, attended plays and concerts, and listened to classical music
Current Occupations:
Lighter work duties as her job: answering questions at the reception desk, answering phones, receiving
requests, and processing paperwork.
Similar hobbies as above, but with increased difficulty due to pain, numbness, and decreased strength.
4: Top Three Client/Family Goals and Priorities
1. Return to completing meaningful activities at work, which include locating research and presenting the
information that she finds to company planner and administrators.
2. Have less pain and discomfort so that she can participate more fully in her hobbies.
3. Complete everyday routines with less discomfort (personal care, household management, and sleeping).
The clients priorities for therapy were not provided in the documentation; therefore, the clients goals above are
inferred based on available information.
5. Diagnosis and Expected Course
Diagnosis:
Carpal Tunnel Syndrome
Trigger Thumb
Rheumatoid Arthritis (previously diagnosed)
Expected Course:
Carpal Tunnel Syndrome:
The prognosis of this repetitive use injury depends

6. Scientific Reasoning & Evidence


List the barriers to performance typical of this diagnosis:
Carpal Tunnel Syndrome:
Pain, tingling, and numbness: These symptoms occur
in the hand and wrist affecting most fingers.
Decreased sensation and weakness (mentioned
below) increase the likelihood of dropping things.
Nighttime occurrence of symptoms: Usually these
problems occur during the night as people sleep with

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on how long it is left untreated. If the median


nerve is compressed for an extended period of
time, numbness, pain, and muscle atrophy result.
However, most people recover fully by making
activity modifications to decrease repetitive
actions, stretching the wrist flexors, wearing
splints at night, getting cortisone injections, or in
more severe cases having a CTR surgery.

flexed wrists. Resulting pain causes sleep


disturbances.
Weakness and atrophy: Compression of the median
nerve left untreated can lead to atrophy in muscles
that it innervates (specifically thenar mm). This can
cause difficulty holding smaller items like
toothbrushes, pencils, eating utensils, razors, and
clothing fasteners. Driving and typing are also often
impacted.
Trigger Thumb:
(All of the above info found in handout from Conditions)
The course of this injury depends on the extent of
Trigger Thumb:
damage to the synovium. Most people recover
Decreased flexion and extension of thumb: Often
after resting the finger and using antiaccompanied by pain, this condition causes a locking
inflammatory medication.
of the finger into flexion. Activities that require
thumb flexion are the most affected and can include
Rheumatoid Arthritis: (previously diagnosed)
playing instruments, typing, gripping a steering
The course of RA is variable. About 20% of
wheel, etc.
people have a single episode of inflammation with
(Pedretti chapter on Arthritis and the Mayo Clinic
a long remission. Most individuals, however,
Website)
experience a series of exacerbations and
Rheumatoid Arthritis: (previously diagnosed)
remissions (flare ups of inflammation followed by
Fatigue: RA reduces an individuals energy level
complete or incomplete remissions). Usually, there
making it difficult to participate in activities that
are four stages of RA:
require endurance.
Stage 1: The synovium becomes inflamed causing
(Mayo Clinic Website)
pain, stiffness, redness, and swelling.
Joint Problems: Misalignment, swelling and pain are
Stage 2: The synovium thickens due to rapid cell
common in RA. This causes difficulty completing
division.
activities with smaller joints. Misalignment can also
Stage 3: Inflamed cells release enzymes that digest
move the hand into a position that is not functional
bone and cartilage, which causes more pain, joint
for everyday activities.
deformities, decreased bone alignment, and loss of
(Pedretti Arthritis Chapter)
movement.
Stiffness: Morning stiffness can last for several hours
Stage 4: Fibrous or body ankylosis results in
and cause difficulty completing morning routines.
addition to stage 3 symptoms.
(Mayo Clinic Website)
Loss of appetite: This symptom can lead to problems
Usually smaller joints are affected first (fingers
with excessive weight loss. As mealtimes often have
and toes) and symptoms progress to the larger
a social component, social participation can also be
joints (elbows, shoulders).
impacted by a loss of appetite.
(Pedretti Arthritis Chapter)
These three conditions have some correlation:
The inflammation and swelling caused by RA can inhibit
tendon gliding in joints, causing trigger thumb. Similarly,
inflammation of the wrist joint caused by RA can compress
the median nerve, causing carpal tunnel. Therefore, these
conditions could be influencing one anothers symptoms and
presentation.
(Orthopedic associates of Michigan website and
Rheumatology.org)

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7. Practice Models Guiding Assessment and Treatment


1.
PEO

Rationale
Marlenes participation in work, household
management, sleep, and personal care will increase
if modifications are made to the activities
themselves, he environment they are performed in
and the way that Marlene engages in them. Below
are some examples of how PEO can be applied to
her hobby of cooking:
The cooking activity itself can be change to
decrease repetitive use of the wrist flexors.
Marlene can choose a recipe that does not
require a lot of cutting or chopping.
The environment that Marlene cooks in can
be modified: she can use appliances to
complete work instead of her hands. A
microwave can be used to warm up soup
rather than stirring it in a pot on the stove.
The way that Marlene engages in the
cooking activity can be modified: Marlene
can use larger joints/muscle groups to move
items. Instead of gripping a pan with her
fingertips, she can place both hands on the
bottom of the pan so that her biceps are
doing the work instead of the muscles that
pass through her wrist joints.
With changes to these three areas, (person,
environment and occupation), cooking will be
easier to complete. Similar modifications can be
made to other activities.

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2.

Biomechanical/Rehabilitation Model:

This model can be applied to all three of Marlenes


hand related conditions. Both remediation and
compensation are essential in Marlenes therapy
and this model incorporates both of these
approaches. Carpal tunnel and trigger thumb can
both be remediated with rest, stretching, and other
similar modalities. The restorative approach can
also be used with RA during remission periods to
build up lost strength due to disuse. A
compensatory approach can be used during
symptom exacerbations to fit activities and
environments to Marlenes current level of
function. Here are some examples of how this
model can be applied to Marlene:
Remediation approach: Splints or braces
can be used to keep the wrist in extension
and decrease tension on the median nerve.
These can be worn during sleep to decrease
Marlenes pain or during repetitive
activities that involve the wrist flexors like
typing. Splints can also be used to keep her
left thumb in extension to decrease the
trigger thumb symptoms (over a weekend
when she does not need to use it as
frequently).
Compensation approach: Marlenes work
environment can be modified to support
her. She can use a voice control program to
operate her computer so that she does not
need to type.

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3.

Lifestyle Balance

Individuals with carpal tunnel, trigger thumb, and


RA are often unable to participate in work and
leisure activities because they have a high level of
pain, fatigue, and movement problems in the hand.
The Lifestyle balance model addresses issues like
fatigue that negatively affect an individuals quality
of life. Here are some examples of how it can be
applied to Marlene:
Delegating roles: If she has the financial
means, Marlene can hire someone to assist
her with demanding home management
activities like cleaning and yard work.
Work simplification: Marlene can cut
unnecessary steps out of activities.
Managing use of energy: Marlene can cook
several meals on a good day and freeze the
leftovers for a bad day (when she has lots of
pain).
Participating in restorative activities:
Marlene can take rest breaks at work to
manage fatigue from RA and median nerve
pain in CTS. She can also wear her braces
at night to decrease pain and increase sleep
quality.
The goal of this model is to achieve life balance in
ones current circumstances through satisfying yet
sustainable occupations. Marlenes life is currently
unbalanced due to the various hand conditions that
she has and the autoimmune symptoms caused by
RA. Treatment framed according to this model will
change the way that Marlene engages in her work
and hobbies to allow for greater satisfaction.
8. Specific Areas of Occupation

What do you know:


Bathing/showering:
Marlene indicated that she has no difficulty
washing her back in the shower on the DASH.
Dressing:
Marlene has some difficulty doffing a sweater.

What do you need to know?


Bathing/Showering:
When does Marlene typically shower? Morning or evening?

Functional mobility:
Marlene stands at a reception area to answer
questions.

Dressing:
Does Marlene have any difficulty getting dressed in the
morning due to wrist pain or morning stiffness?
What aspect of undressing is difficult for Marlene? Fasteners?
Fatigue or pain at the end of the day?
Eating/Feeding:
Does Marlene have any difficulties holding eating utensils?
Pain? Dropping items?
Functional mobility:
Does standing at this area cause any fatigue? How long does
she need to stand for?

Personal Device Care:

Personal Device Care:

Eating/Feeding:
None

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She has been issued braces by her doctor.


Personal hygiene and grooming:
She reports some difficulty blow-drying her hair.
Personal care tasks were listed at 90% function
in the documentation.

Sexual Activity:
She reported N/A in this category on the DASH
Toilet Hygiene:
None
Communication Management:
Marlene regularly makes phone calls for work.

Community Mobility:
Marlene drives a car.
She has difficulty turning keys.
Financial Management:
Marlenes occupational therapy visits are paid
for by insurance and workers comp.
Health Management and Maintenance:
Marlenes employer allows her complete light
duty tasks due to her RA.
She is reluctant to have CTR surgery because
she does not know how she will manage on her
own during recovery.
She is currently on medications for pain and
joint swelling.
Home management and Maintenance:
Marlene lives alone and likely completes most of
her home management activities.
She indicates that she has moderate difficulty
with household chores and documentation
indicates that she has 70% function in this
category.
Meal Preparation and Cleanup:
Marlene enjoys cooking.
Marlene indicated that she had moderate
difficulty with meal preparation.
Religious Observance:
None
Shopping:
She has moderate difficulty holding a shopping
bag.

Has she been wearing these braces? How does she plan on
washing them if she needs to?
Personal hygiene and grooming:
What personal care activities are going well/not so well?
Does she have any morning stiffness or UE pain during
grooming activities?
Is she able to hold onto smaller items (toothbrush, makeup
applicators, comb, finger nail clippers, etc).
Does she have difficulty gripping her hair dryer and brush? Or,
does she have difficulty holding her arm up for an extended
period of time?
Sexual Activity:
None
Toilet Hygiene:
Does she have any difficulties with clothing management
during toileting?
Communication Management:
Does Marlene have any difficulty pushing buttons to dial a
phone number?
How does she communicate with friends/family? Does she text?
Does Marlene need to send a lot of emails for work?
Community mobility:
Is it difficult to grip the steering wheel of her car?
Does her car unlock with a button or does she need to turn a key
to open it?
Financial Management:
Does Marlene have the financial means to hire any help with
home management activities?
Health management and Maintenance:
What stage of RA is Marlene in? (Likely 1 or 2)
Do her medications have any negative side effects?
When is she wearing her braces?
Is she currently using any strategies to manage her diagnoses?
(Stretching, tendon gliding exercises, using larger joints
whenever possible, avoiding repetitive wrist flexion, etc).
Home management and Maintenance:
Does Marlene need to turn a key to get inside her home?
What aspects of home management or specific chores are
difficult?
Does Marlene currently have anyone who is available to assist
her with home management activities?
Meal Preparation and Cleanup:
How often does Marlene prepare a meal? How complex is it?
What steps are involved?
Religious Observance:
Does Marlene identify with a particular religion?
Shopping:
How does Marlene get her groceries or other purchases to her
car? In a cart? Carry them?
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Rest/Sleep:
She has moderate difficulty sleeping because of
pain in her UE.

Education:
Given her career field, Marlene has likely
graduated high school and gone to college.
Work:
Marlene works as a reference consultant for a
scientific research company.
Prior to her onset of symptoms:
-She spent about 5 hours per day (but more as of
lately) using a computer to search for reference
data and internet sites.
-She spent about 3 hours per day standing and
answering questions at a reception area.
-She spent about 10 hours per week on the phone
and meeting with planners and administrators.
Since her health condition worsened, her
insurance requires her to remain on the job in
light duty roles:
-Time at reception desk responding to questions
-Answering phone
-Receiving requests
-Processing paperwork
She considers these activities less meaningful.
Since the onset of her symptoms she has also
needed to make a more conscious effort about
what to do and how.
Overall, she reports that her diagnoses and
associated symptoms have a slight impact on her
daily schedule.
Volunteering:
None
Leisure Participation:
Marlenes hobbies include:
-Cooking
-Reading
-Watching TV
-Going to plays
-Going to concerts
-Listening to classical music
Social participation:
Marlene lives alone.
Marlene answers questions for people in a
reception area
Marlene meets regularly one on one with
coworkers to discuss her research.

Does she have any difficulty pushing a shopping cart?


What type of purse does she use and how does she wear it?
Rest/Sleep:
How often does Marlenes wake up because of pain?
How many hours of sleep does she get per night? Is she
satisfied with this and does she feel rested?
Does Marlene take any rest breaks throughout her day?
Education:
None
Work:
How supportive is Marlenes employer? Is he/she willing to
make workplace modifications? If Marlene expressed her
decreased satisfaction with her current workload, would her
employer be willing to make adaptations to her schedule or
other duties so that she could resume these valued activities?
Who is insisting that Marlene continue to work during this
period of time? Her employer? Her insurance? Can this
group/person be negotiated with to decrease work hours?
Would Marlene be able to take time off of work for a CTR
surgery? How much vacation and sick leave does she have?
How much time does Marlene get off for holidays, specifically
the upcoming holidays of Christmas and New Years?

Volunteering:
Does Marlene volunteer anywhere and if so, how is that going?
Leisure participation:
How has Marlenes leisure participation changed since her
change in health status on Nov 1?
On the DASH, what does Marlene mean when she says that she
has some difficulty with holiday things in the recreation
category?

Social participation:
Does Marlene have any social supports in her local community?
Is she spending time with any family/friends for the upcoming
holidays? Would they be willing to assist her if she decided to
get the CTR surgery?
Is Marlene missing out on any social activities because of her
pain level?
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Other:
How does Marlene spend her time on a good day versus a bad
day?
How has Marlenes typical day changed since her symptoms
worsened at the beginning of November?
What is Marlenes classification of function according to the
American College of Rheumatology?
What are her goals for therapy?
9. Performance Skills
What do you know?
Motor and Praxis Skills:
Marlene reports weakness in digits 2-4 on her right
hand.
Marlene has bilateral grip weakness (below average
range in both hands).
She has decreased pinch strength
-Lateral pinch: Well below average bilaterally
-3 point pinch: Well below average bilaterally
-Tip pinch: Well below average in right hand,
normal range in left.
She has decreased wrist ROM:
-Bilateral wrist flexion: loss of 20 degrees on the
right and 30 degrees on the left.
-Left wrist extension (mild): loss of 7 degrees.
Decreased Thumb flexion and extension (secondary to
RA and Trigger thumb)
-Thumb MP (on the left): loss of 8 degrees
-Thumb IP (bilateral): loss of 18 degrees on the
right and 12 degrees on the left.
Bilateral index fingers have full ROM, however, they
require very concentrated effort to get to full range.
Scoring on the DASH indicates a high level of
dysfunction in the upper extremity. Her score was a 90.
A score of zero indicates no dysfunction and a score of
100 indicates severe dysfunction.
The deficits listed above impact Marlenes participation
in everyday activities, particularly those that involve her
upper extremities (turning a key, operating/typing on a
computer).
Sensory Perceptual Skills:
Marlene has decreased light touch sensation on her left
distal volar phalanx. However, her protective sensation
is still intact.
She has normal sensation in her right hand.
She reports numbness in digits 2-4 (secondary to median
nerve compression).
Emotional Regulation Skills:
None

What do you need to know?


Motor and Praxis Skills:
Does Marlene have any difficulty standing for long
periods or maintaining balance?
What is Marlenes strength in individual UE muscle
actions?
When does Marlenes trigger thumb occur? During
which activities? How long does it remain in a flexed
position?
Does Marlene demonstrate any guarding when she has
UE pain?
Is Marlenes right hand used more often as it is less
affected than her left hand?

Sensory and Perceptual Skills:


Does Marlenes decreased sensation have any impact on
her participation in occupations?

Emotional Regulation Skills:


How is Marlene processing her diagnoses and the
changes she experienced since her symptoms recently
worsened?

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Cognitive skills:
None

Communication and Social Skills:


Marlene has sufficient communication and social skills
to complete lighter job duties (phone calls, answering
questions).

Does Marlene experience any symptoms of depression?


Any frustration or feelings of a loss of control?
Any other difficult psychosocial adaptations that have
occurred since her diagnosis or RA, CTS, or trigger
thumb?
Cognitive Skills:
Does Marlene experience any cognitive problems
secondary to pain or sleep disturbances? (Shorter
attention span, problem-solving difficulty?)
Communication and social skills:
None

10. Performance Patterns-Habits, Routines, Rituals, Roles


What do you know?
Habits:
None

Routines:
Marlene will attend therapy each week for 2 months.
Marlene goes to work 40 hours per week.
Marlenes availability for therapy is dependent on her
busy schedule.

Rituals:
None
Roles:
Marlene is an employee.
Marlene is user of technology.
Marlene is a client of OT services.

What do you need to know?


Habits:
What type of purse does Marlene use and how does she
wear it?
What activities does Marlene complete with her left
hand only?
Routines:
Is Marlenes employer open to giving her different job
duties that are more meaningful to her?
What does her typical day look like? Specifically, what
do her morning and bedtime routines look like? What
does she do when she is not at work?
What does her meal prep routine look like?
Rituals:
Does Marlene associate with a particular religious or
ethnic culture? If so, are there any associated rituals?
Roles:
Are there any roles that she has not been able to
maintain since her symptoms worsened?
What other roles does Marlene have and what is
expected of her in each (For example, if she is a
volunteer, what is she expected to do to fulfill this role?)

11. Activity Demands for the Client Goals and Priorities:


Activity: Day at work
What do you know?
What do you need to know?

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Objects and Properties:


Marlene needs to sit in a chair at her desk while she uses
a computer.
Marlene needs to operate a phone.
Marlene needs to lift books.
Social demands:
Marlene needs to answer questions at the reception area.
Marlene needs to talk with people on the phone.
Marlene needs to locate research and report on this
findings with coworkers.
Sequencing and timing:
Marlene is required to stand at the reception area for 3
hours per day.

Required Actions/Performance Skills/Body Functions:


Marlene needs problem solving skills to locate research
that is relevant to her companys needs.
She needs attentiveness and composure to respond to
questions in the reception area and answer the phones.
Marlene needs UE strength to lift books.
Marlene needs fine motor skills, joint mobility, and
dexterity for typing and dialing phone numbers.
She needs good endurance to stand for prolonged
periods of time.

Objects and properties:


How heavy are the books that she is required to lift?
Does she have her own private office?
Does her computer have voice control technology?
What type of keyboard and mouse does she use?
Social demands:
Are there any clothing expectations at Marlenes work?
Is she allowed to wear braces, splints, or other devices
to decrease pain and joint problems?
Sequencing and timing:
Is the amount of standing time broken up into smaller
periods? If it is not currently, can it be?
What type of deadlines or time constraints does Marlene
need to meet at work? How long does she have per
research project?
Required Actions/Performance Skills/Body Functions:
What is the minimum UE strength that Marlene needs to
complete her job duties (lifting books)?
Does Marlene use any compensatory strategies at work
to accommodate her pain and UE weakness?

12. Client Factors- Values, Beliefs, Spirituality


What do you know?
What do you need to know?
Values:
Values:
Marlene values research and locating information that is Does Marlenes employer value her research
relevant and useful to her company.
contributions to the company?
Does Marlene feel like she has too many responsibilities
given her condition (full time work, responsible for all
home management, etc)?
Does Marlene place a high value on physical appearance
(does splint wearing or abnormal appearance of joints
bother her)?
Beliefs:
Beliefs:
Marlene reports that she has not suffered decreased
Is Marlene willing to advocate for some form of
confidence or felt less useful since her diagnosis.
participation in meaningful work activities?
Is she willing to ask family or friends for help after a
CTR surgery?
How does Marlene feel about simplifying her work
activities? Is she willing to make some adjustments to
how she completes everyday routines?
What are her hopes/goals for therapy?
Is she open to using assistive devices to compensate for
decreased hand function?
Spirituality:
Spirituality:
None
Does Marlene affiliate herself with a religion? If so,
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how has this affected her outlook on her recent


diagnosis?
13. Client Factors- Body Functions & Structures
What do you know?
What do you need to know?
Mental functions:
Mental functions:
Marlene has enough mental ability to complete work
Is Marlene experiencing fatigue?
full time job duties as a research consultant.
Does Marlenes pain level cause her any difficulty
sustaining attention?
Is Marlene experiencing any malaise that often
accompanies RA?
Sensory and Pain:
Sensory and Pain:
Marlenes highest pain level is usually between a 5How does pain level vary between various activities or
6/10.
times of day?
She reports occasional bilateral elbow and shoulder
Is pain at a higher level during certain activities? At a
pain.
specific time of day?
She reports severe pain in the UE on the DASH.
If Marlene has been wearing the braces ordered by the
Her distal UE are affected more frequently than her
doctor, have they decreased her pain?
proximal UE.
Decreased sensation, weakness, and numbness in digits
2-4 results from compression to the median nerve.
Marlenes pain level causes difficulty sleeping.
Neuromusculoskeletal and Movement Related:
Marlenes median nerve compression in her carpal
tunnel caused muscle weakness in her hand.
Marlene reports moderate stiffness of the arm, shoulder
and hand.
Cardiovascular, hematolocial, immunolical and
respiratory:
Rheumatoid arthritis is a chronic autoimmune disorder.
Synovial cells produce enzymes that destroy cartilage
and bone.
Skin:
None

Neuromusculoskeletal and Movement Related:


Has Marlene experienced any RA symptoms in her LE?
Stiffness or joint deformities of the hips/knees/ankles?

Body Structure:
Marlenes bilateral median nerves are compressed in the
carpal canal, which caused muscle atrophy.
Marlene has nodules in her left thumb that prevent the
flexor tendon from going smoothly through the tendon
sheath.

Body Structure:
Does Marlene have any joint deformities secondary to
RA?
Does Marlene have any nodules or crepitus secondary to
RA?
How much inflammation does Marlene have in her wrist
joints? Is this inflammation impacting her median nerve
or tendon sheaths?

Cardiovascular, hematolocial, immunolical and


respiratory:
None

Skin:
Has Marlene experienced any skin changes recently?

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14. Evaluation: What Assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize one Occupation to observe the client perform
Observed Occupation
Prepare a meal (a typical meal that she would make for
herself).

Method/Tool
1. Interview Marlene about:
-When she experiences the most pain and what
activities she is typically doing then
-What her life looks like outside of work
-How she is feeling about the CTR release
surgery (as her decision affects therapy
approach)
-What social supports she has
-How supportive her employer is
-What activities are the most frustrating for her
-What are goals are for therapy. Confirm if the
current priorities are an accurate picture of how
she would like to spend her therapy time.

Rationale/How will you use this information


This occupational requires a variety of skills discussed
in Marlenes referral. Marlenes daily work functions
require similar skills and abilities as this activity.
Current knowledge of activities that exacerbate
carpal tunnel and trigger thumb: Does she
choose a recipe that requires lots of repetitive
chopping? If so, she may not be aware that such
movements can worsen these conditions.
Her level or pain during a daily activity and how
she responds: If she is in a lot of pain can she
still follow the recipe instructions? This may
indicate how she responds to work tasks when
she is not feeling well.
Standing tolerance/level of fatigue: This will
indicate the degree to which Marlenes RA has
affected her activity endurance. This
information indicates how long she maybe able
to stand at the reception area at work.
Current knowledge of joint protection strategies:
Does she use larger joints and muscle groups
during this activity (Lifting with her whole hand
instead of her fingers)? This will indicate if she
regularly makes activity modifications in other
areas (perhaps even unconsciously because of
high pain).
Rationale/What is being Assessed
I did not complete her evaluation; therefore, I would
like to have a short discussion to better understand
Marlenes experience with her diagnoses. Although
CTS/Trigger thumb/RA have a given set of symptoms, I
want to know more about how the diagnoses have
affected Marlenes daily life outside of work. How have
her morning routines, mealtimes, bedtime routines,
social outings, and hobbies been affected? Also, in
order to make therapy more client centered, I would like
to discuss her priorities and goals so that I can address
these in therapy.

Page 13 of 19

Revised 1/7/13

2. Cognitive screening

3. Psychosocial Screening

4. A Home Evaluation

5. MMT on bilateral UE

6. AMPS

Although CTS/Trigger thumb/RA do not directly affect


cognitive status, many of the symptoms that accompany
these diagnoses can affect attention plan and problem
solving skills. High levels of pain and difficulty
sleeping can drastically affect the ability to think
clearly. Because Marlene has complained of high pain
and difficulty sleeping, I want to see if there are
associated difficulties in this area. If there are any
cognitive problems, I can focus my treatment on
decreasing her pain level and promoting better sleep
and communicating with her physician about pain
management options.
Marlene is in a lot of pain throughout her daily
activities (day and night). These painful symptoms
came on very suddenly which could cause feelings of a
loss of control and depression. Marlene also has RA and
studies indicate that approximately 20% of people with
RA also have major depression. Because of her
previous RA diagnosis, sudden onset of symptoms, high
pain level, and decreased involvement in meaningful
work activities, Marlene may have some associated
psychological problems. If she does, a referral can be
made to a counselor or psychologist.
Marlene reported that she has difficulty with home
management activities. Her current documentation
provides very little information about what activities are
difficult, what type of home she has, and what duties
she expects herself to complete. A home evaluation will
provide more information about what her home
environment is like so that modifications can be made if
necessary. Suggestions can also be made about function
more efficiently in her environment (how to complete
meal preparation with less stress on her joints, for
example).
I know that Marlenes is experiencing weakness and
decreased grip/pinch strength, however, I do not know
her muscle strength of specific UE muscle actions. This
information (combined with ROM, grip/pinch) will
provide more a very specific idea about where
Marlenes deficits are located. Activates can be
implemented to strengthen these weak muscles during
periods of remission from RA. Activities can also be
modified to avoid loading too much weight on these
weaker muscles.
This assessment examines motor skills during
functional tasks. I currently have a lot of information
about Marlenes motor skills, but less information about
how these skills impact her functionally in specific
activities. This assessment will provide information
about Marlenes endurance, object manipulation, and
movement coordination during a variety of activities.

Page 14 of 19

Revised 1/7/13

15. Projected Outcomes:


As acute conditions, carpal tunnel and trigger finger can be remediated with
assistance from OT services. Both conditions are repetitive use injuries that can
be remedied with surgery (should Marlene choose this route) or activity
modifications to decrease stress on the wrist and thumb flexors. If Marlene
wears braces as instructed and minimizes her repetitive activities on her
wrist/thumb flexors, she should have:
Less pain in her UE
The ability to balance work and rest to have less pain on the job.
Less numbness in her UE
Better sleep quality
More participation in the long term (activity modifications may decrease
or change short term participation so that symptoms of these conditions
can subside.)
Greater satisfaction with work roles.
Greater satisfaction with leisure participation
The knowledge to prevent CTS and trigger thumb in the future.
Participation in a splint wearing routine/schedule to decrease pain and
inflammation
As a chronic condition, rheumatoid arthritis has a different outcome. Marlene
will have this condition permanently and the symptoms will likely get worse as
time passes. Although OT services cannot stop the course of RA, it can assist
Marlene in coping with its symptoms. At D/C Marlene will have:
The ability to employ work simplification techniques
The ability to use joint protection techniques
The ability to decrease the impact that RA has on participation in
meaningful activities.
After occupational therapy services, Marlene should be have a substantial
decrease in symptoms of carpal tunnel and trigger thumb. She should also have
greater ability cope with symptoms of RA so that she can engage in tasks that
she enjoys.

Type of Outcome
Occupational Performance
Prevention
Adaptation
Health and wellness
Participation
Quality of life
Role competency

16. Resources and Team Members

Page 15 of 19

Revised 1/7/13

Community resources:
Techrepublic.com or www.geeks.com/techtips: These websites provide information about ergonomic
technology options for people with CTS including keyboards, mouses, notepads, etc.
Web MD: This website provides a list of carpal tunnel stretches and trigger thumb exercises.
You tube videos: There are a lot of demonstrations of and trigger thumb exercises and CTS stretches.
The Arthritis Foundation: This organization provides a wide variety of services including how to manage RA
during a variety of activities (gardening, work), community exercise and recreation programs, and self-help
programs. Individuals who have gone through the self-help program have reported a decrease in pain of 20%.
Rheumatoid arthritis support group: Meeting with people in the local community who also have RA could be
very beneficial for Marlene. Other individuals who have co-occurring conditions of CTS or trigger finger may
be able to give Marlene advice or identify with her symptoms.
RA monthly e-newsletters: These have info about the latest research in RA and new treatment options.
Team members:
Marlenes employer should be contacted to discuss how to provide her meaningful work opportunities.
Her physician and hand surgeon can provide info about the recovery process from CTR surgery and pain
management options, which will impact how therapy time is spent.
If Marlene has social supports in her community, they may be able to assist her with some home management
17. Intervention Plan
Barriers
Marlene enjoys researching on the computer but repetitive
motions like typing on the computer exacerbate her CTS and
trigger thumb.
Marlene has difficulty with home management activities but
she lives alone and therefore has full responsibility for them.
Marlenes main work duties (20-30 hours/week) require
typing, dialing numbers, lifting books and other activities that
require good hand function.
Marlene would benefit from CTR surgery but does not feel
that she has sufficient social supports assist her in the
recovery process.
If workers comp is paying for some OT services, they may
specify that therapy address work related functions only.
Goals

Supports
Marlene is receiving OT services
early on after her symptoms
worsened.
Marlene has a wide variety of
interests that can be used in
therapy.
Marlenes insurance covers enough
OT visits to work on a variety of
activities.
In addition, outpatient setting
allows for the opportunity to
address a variety of occupational
areas.
Practice Model for each goal

LTG:
By D/C, client will problem solve one work simplification technique
during a work related activity with min verbal cues.
STG:
By session 3, client will independently use a joint protection
technique while handling an office related item that weighs more
than 5 lbs.

STG:
By session 6, client will independently implement a one-minute rest
break every 30 minutes while typing on a computer.

Page 16 of 19

Lifestyle Balance

Biomechanical

PEO

Revised 1/7/13

2. LTG:
By D/C, client will receive 7 hours or more of sleep per night for at
least 5 consecutive days as recorded in a sleep chart.

Lifestyle Balance

STG:
By session 2, client will wear braces at least 5 nights per week to
maintain extended wrist position.

PEO

STG:
By session 6, client will report an overall score of 3 or less on the
pain intensity scale upon waking for the previous week.

Biomechanical

3. LTG:
By D/C, client will independently implement rest breaks prn during
home management activities involving the UE.
STG:
By session 7, client will problem solve an activity modification
during meal preparation to decrease wrist flexion with min verbal
cues.
STG:
By session 3, client will utilize joint protection techniques during
household cleaning activities independently.

Lifestyle Balance

PEO

Biomechanical

18. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do?
Identify Approaches

Page 17 of 19

Based on which goal(s)?

Revised 1/7/13

This session will consist of client education about


strategies that can be used to decrease CTS and trigger
thumb symptoms at work. Advice about RA management
strategies in the workplace will also be addressed. The
outpatient clinics computer stations will be used to
demonstrate some modified techniques for typing, writing,
holding books, and using a computer mouse. The following
ideas will be presented:
Taking 1-2 minute breaks from typing every 20-30
Establish/Restore
minutes and especially when pain/tingling starts.
Marlene can remain productive during breaks by
reading research that she has located and
formulating her thoughts about what aspects are
relevant to her company.
Completing stretches and tendon gliding exercises
to decrease pressure on the median nerve. The
client will be instructed on a few of these stretches
(the prayer stretch and wrist flexor stretch).
Wearing splints or braces while typing to keep her
wrist in extension if they do not get in the way of
the finger movement needed to press keys. There is
also a small thumb splint that keeps thumb from
flexing for trigger finger.
Avoid gripping a telephone for a prolonged period
of time. Use speakerphone or support the phone
with the shoulder.
Use the entire hand to hold a book at rather than
Modify/Alter
gripping the spine with the fingers.
The client will also receive information about various
office equipment that may assist in work related activities:
Ergonomic keyboards that decrease strain on the
hand.
Wrist cushions to keep the wrist in a comfortable
position.
Ring pens that fit around the finger to eliminate
gripping.
A vertical mouse that operated with the wrist in a
slightly extended position.
Voice control programs can operate a computer,
click on icons and type sentences so Marlene would
not need to type or use a mouse at all if here pain
level was too high.
Marlene will be able to return to more meaningful work
activities if she is able to adjust to their high demands with
less pain. The various equipment options and techniques
above should also assist her in participating in work
activities that she enjoys.

2. What will you do?

Identify Approaches
Page 18 of 19

By D/C, client will


independently implement a
one-minute rest break every
15 minutes while typing on
the computer.

By session 6, client will


problem solve a work
simplification technique
during a work related activity
with min verbal cues.

Based on which goal(s)?


Revised 1/7/13

This session will also consist of client education and


practicing new techniques. The ideas presented will be
related to home management related activities:
Avoid using a strong grip whenever possible. If jars
are not on tight, they can be opened with loose grip.
Use appliances to assist with meal prep instead of
doing the work manually. A food processor in a
slow setting can be used instead of chopping with a
knife.
While gripping a broom or mop, take rest breaks to
stretch the wrist.
Instead of squeezing a sponge to scrub or clean,
extend the palm and place a disinfecting wipe on it.
Modify/Alter
This uses larger joints, places less stress on the
fingers, and keeps the wrist extended.
Use joint protection whenever possible. Brush
items into hand instead of picking them up one by
one with the fingers. Use feet instead of hands to
close drawers. Use body weight to push open a
door instead of an arm.
Implement rest breaks frequently and complete
stretching exercises. Identifying when rest breaks
need to occur will also be discussed (onset of
fatigue, pain, or during a prolonged repetitive
activity).

Page 19 of 19

By session 3, client will


problem solve an activity
modification during meal
preparation to decrease wrist
flexion with min verbal cues.

By session 7, client will


utilize joint protection
techniques during household
cleaning activities
independently.

By D/C, client will


independently implement rest
breaks prn during home
management activities
involving the UE.

Revised 1/7/13